2016 Convention CE Schedule for Optometrists Friday, April 15, 2016 Registration located in the Grand Foyer 1-3. Unless otherwise noted, all breakfast and breaks will be served in the Grand Foyer 4. Lectures will be held in Grand 5. 7:30 – 9:30 am

Registration & Continental Breakfast Support provided by ABB Optical Group

As the Affordable Care Act unfolds, expanded health plan coverage may increase the number of children receiving comprehensive eye examinations, including those with undiagnosed ocular and systemic disease. This course will present a series of unusual cases to illustrate dilemmas in diagnostic testing, diagnostic technology use, and short and long-term case management in the pediatric population. COPE 45371-FV, 2 Hours IOB

A practical approach to the identification, diagnosis and management of basic vergence and accommodative disorders is presented. Basic diagnostic testing as well as a comprehensive overview of different treatment approaches for each condition is discussed. Case presentations are included as examples of diagnosis and treatment of binocular conditions. COPE 48162-FV, 1 Hour IOB

This course reviews the current scleral lens applications for regular and irregular corneas. The differences between scleral lenses and corneal gas permeable lenses are addressed. Ten categories of patients are defined; good scleral lens candidates are identified; and the benefits of scleral lenses are highlighted. Customization of scleral lenses including notching, diameter changes, front surface toricity and toric haptics is presented in detail. Presentation of scleral lenses to the patient is discussed, and the fitting process and follow-up care is reviewed. COPE 46827-CL, 2 Hours IOB

Are you still having difficulty integrating oral pharmaceuticals into your practice? Intimidated by potential side effects? This course reviews the principal medications used by optometrists for oral therapy, questions that should be asked before prescribing, and appropriate follow-up protocols to monitor patient response and to manage any developing side effects. Emphasis is placed on antibacterials, antivirals, steroids and medications for pain. COPE 45000-PH, 1 hour IOB/Legend Drug

This course challenges all attendees to provide the very best contemporary pharmacologic treatment for every patient cared for in today’s primary care optometric practice. FDA-approved medications, current peer-reviewed published literature and treatment protocols sanctioned by the AOA Clinical Practice Guidelines and the American Academy of Ophthalmology Preferred Practice Patterns will be emphasized. Move your practice into the 21st century by adhering to these new guidelines and treatment protocols. COPE 45064-PH, 2 Hours IOB/Legend Drug

This course reviews current intravitreal injection medications and the various diseases for which they are used. The presenter has been doing these injections since 2006. A video of the procedure will also be shown. COPE 37749-PS, 1 Hour IOB/Legend Drug

This course will differentiate headache types that are accompanied by visual symptoms. Emphasis will be on migraine headaches and its treatment with oral pharmaceuticals. COPE 42671-OP, 2 Hours IOB/Legend Drug

Indians Baseball Game at Victory Field Support provided by Vision Source & Essilor

Located in the Coors Light Cove, 21 and over only. ALL TICKETS HAVE BEEN RESERVED FOR THIS EVENT. Tickets were available upon registration on a first come, first served basis. If you decide not to attend the game, please return your tickets to Bridget Sims at the IOA registration desk as we have a waiting list.

8 – 10 am What the Primary Care Optometrist Should Never Miss Ron Melton, OD, FAAO, Charlotte, NC and Randall Thomas, OD, FAAO, Concord, NC As an optometrist on the front lines of patient care, there are certain conditions that are encountered in which it is critical to make the correct diagnosis and treatment plan. This course will present a variety of ocular disease states that if not taken care of appropriately could lead to permanent vision loss or even loss of life. A review of the conditions the optometrist should never miss will be discussed. Actual case examples will be shown based on the team’s years of clinical experience. COPE 41897-SD, 2 Hours IOB/Legend Drug

This course unlocks the secrets to dealing with common and not so common ocular disease entities. It includes an overview and update of diagnosis and treatment options for dealing with multiple case presentations. COPE 41895-AS, 2 Hours IOB/Legend Drug

The Westin Indianapolis FLOOR PLANS

Capitol III

Capitol II

Council FIRST FLOOR

Chamber Capitol I

Caucus Cabinet

Cameral

Front Desk Congress

Lobby

Grand 5

SECOND FLOOR

Grand Foyer 4

Grand Ballroom Grand 4

Grand 3 Grand 2

Grand Foyer 1-3

House

Senate 3

Senate 2 Senate 1

Grand 1

State

President’s Welcome! Dr. Todd Niemeier

I would like to welcome everyone to the 119th Annual Convention of the Indiana Optometric Association. We hope you enjoy the beautiful Westin Hotel and are able to spend some time in downtown Indianapolis. Dr. Dennis Miller has done another outstanding job of bringing in nationally renowned speakers. I would also like to thank convention chairs Chris Browning and Nick Garn for all of their efforts in organizing our convention. They have put in countless hours to bring in corporate sponsors and vendors as well as work out the logistics of the convention. Please take time to thank these three for their efforts. Also, as you take time to tour the exhibit hall, please thank our vendors and sponsors for their support of Indiana OPTOMETRY. As I have traveled the country over the past couple of years for AOA events, it has become obvious to me how special our central office staff is. I would like to thank Jim Zieba, Barb McNutt, Bridget Sims and Lisa Sheridan. They have worked very hard to prepare for the convention. The character of our staff is second to none. I would also like to thank our immediate Past President Darren Minnich. He has been a great leader for Indiana OPTOMETRY and a great mentor to me. We will recognize our award winners at our Friday Luncheon as well as listen to our incoming president Jeff Yocum. I believe you will see his passion for Optometry, and I am confident he will be a great leader. You will have the opportunity to wish him well at Friday’s Welcome Reception sponsored by Eye Surgeons of Indiana and Saturday’s President’s Reception sponsored by Eye Specialists of Indiana. It has been an honor working with so many great volunteers. I would like to thank them and all of you who helped make this organization what it is today. Because of your membership, we are a stronger Indiana Optometric Association. The future of Optometry is bright. In this legislative session, we have witnessed how important it is to have an organization like Indiana Optometry working on our behalf and the patients we serve. Enjoy your stay in Indianapolis! Sincerely, Todd Niemeier

STATE OF INDIANA OFFICE OF THE GOVERNOR State House, Second Floor Indianapolis, Indiana 46204

Michael R. Pence Governor

April 15-17, 2016 Indiana Optometric Association 10 W. Market Street Suite 2995 Indianapolis, IN 46204 Greetings, It is a pleasure to welcome you to the Indiana Optometric Association’s 119th Annual Spring Convention in our capital city. On behalf of all Hoosiers, thank you for your strong efforts, actions, and ideas that contribute to making health care programs effective. Moreover, I offer my profound gratitude for your commitment to bettering the health care community as a whole. I hope this year’s conference provides you with an opportunity to share best practices and improve the optometry field. I would like to thank The Westin Indianapolis for hosting this event, and I wish all in attendance an enriching conference. Sincerely,

Michael R. Pence Governor of Indiana

2016 Convention Exhibitors Please visit the vendors who support the IOA Convention. Premium exhibitors will be available for two full days, Friday and Saturday. The exhibit hall is open during the Friday night Welcome Reception from 5:30-7:30 pm and the Trade Show Luncheon on Saturday from 11 am- 2:30 pm.

*Indicates booths that will have a raffle drawing. Attendees must visit participating exhibitor booths to enter raffle contests and be present to win. Drawings will begin on Saturday at 12:30 pm. **Visit Indiana University’s booth for an opportunity drawing. CONVENTION GRAND PRIZE - Drawing at 1:25 pm. Gift certificate courtesy of The Westin Indianapolis for a deluxe room for two. All registered ODs are automatically entered in this drawing. Must be present to win.

2016 Exhibitor Map

Grand Foyer 4

Indiana OPTOMETRY Exhibitor Hours

Premium exhibitors will be available for two full days, Friday and Saturday, in the Grand Foyer 4. The Exhibit Hall is open during the Friday night Welcome Reception from 5:30-7:30 pm and the Trade Show Luncheon on Saturday from 11 am- 2:30 pm.

Incoming President

Dr. Jeffrey Yocum Dr. Jeffrey Yocum graduated from Ottawa Township High School, Ottawa, Illinois, in 1979, where he was a three sport athlete in football, basketball and baseball. He chose to play baseball at Eastern Illinois University, achieving academic All-American status his senior year. While at EIU, his sophomore team was NCAA D2 National runner up in 1981. He received his BS Zoology with honors in 1983. During the summer of 1982, he and former roommate major leaguer Kevin Seitzer won the prestigious Cape Cod Baseball League for the Chatham A’s. He chose a career in optometry over baseball, graduating with his Doctorate of Optometry from Indiana University in May 1987. While at IU, he completed externship clinical at IU-B CL Clinic, Illinois Street Indianapolis, Huntington, WV NAMC, and Chanute AFB Rantoul, IL. He served the IU-B Biology Dept. as an associate lab instructor in 1984 and 1986. Upon graduation, he accepted an associateship opportunity with Dr. Philip Ortiz in Morris, IL. His OD/MD relationship there also expanded to the Joliet and Bourbonnais, IL offices. He chose to return to Indiana in the fall of 1990. Early in 1991, he approached longtime IOA member Dr. Richard Davis about practice opportunities in downtown Lafayette. He purchased Dr. Davis’ practice in late 1991, where he continues to practice to this day. His staff of seven provides full scope optometry at 637 Ferry Street. He plans to add an associate optometrist in the summer of 2017. Dr. Yocum is a 32-year member of the AOA and 26-year member of the IOA. He served all offices of his local Tecumseh Optometric Society. He was the Western Trustee from 1997-2001. He was elected to the IOA Executive Board in the spring of 2013. Locally, Dr. Yocum and his wife of 31 years, Cathy, a licensed physical therapist, have four children, two grandchildren and attend Grace Lutheran Church, Lafayette. His oldest daughter, Whitney (RN @ IU Simon Cancer) and her husband, Nathan Misch, live in Lafayette with their children, Nevyn and Brody. Their daughter, Jacqui, a licensed Occupational Therapist at St. Franciscan, Lafayette, is engaged to Kyle Misch and planning a September wedding. Son, Jacob, is a 2014 graduate of University of Indianapolis and a four year letter winner in golf as well as a former All-Stater at Lafayette Jefferson High School. Their youngest son, JT, a three sport athlete and former college baseball player, is finishing school towards a nursing degree in St. Louis. Dr. Yocum is an active member and former president of the Lafayette Breakfast Optimists. He also coached several years of travel baseball and basketball. He continues to referee high school varsity football and basketball in Indiana. Dr. Yocum supports Optometric missions by donating recycled glasses and in 2007 participated on a mission trip to Belize.

Outgoing President

Dr. Todd Niemeier

Dr. Todd Niemeier graduated from Mater Dei High School in Evansville, Indiana. He then attended and graduated from the University of Southern Indiana in 1995 with a B.S. in Biology. While there, he played baseball for four years. In 2002, Dr. Niemeier graduated with his Doctorate of Optometry from Indiana University. Upon graduation, he moved back to his hometown of Evansville. He purchased the practice where he grew up as a patient from Dr. A.C. Stocker. Dr. Niemeier’s optometrist growing up was the late Bob Gregg (president of the IOA, 1971-1972). He continues to practice at the same location on Franklin Street that was established in 1955. Dr. Niemeier is an 18-year member of the AOA. He served in all of the offices of the Southwestern Society before serving two terms as a Western Trustee. He has served as the Secretary-Treasurer, Vice President and President Elect. He was awarded the President’s Citation (Young Optometrist of the Year) in 2008. Locally, Dr. Niemeier is a member on the spiritual life committee at Resurrection Catholic Church. He is a member of the Mater Dei Men’s club, which supports all sports at his alma mater. Dr. Niemeier is also a life member of the Tri-State Hot Stove League, which supports youth baseball and softball in the greater Evansville area. He also enjoys coaching his daughters’ basketball, softball and soccer teams. Dr. Niemeier met his wife Babs while playing minor league baseball. He and Babs’ brother Jeremy were on the same team. They married in 2003 and have two children, Olivia and Marissa. The Niemeier’s have hosted Evansville Otters minor league baseball players during the summers since 2004.

A Gift For You... Matt & Jon from Wind River Financial look forward to meeting you. Stop by the Wind River Booth with a monthly credit card statement for a free cost comparison, and Wind River will give you a $50 Visa Gift Card redeemable at any business that accepts Visa! Family-owned Wind River Financial is the IOA’s endorsed credit card processing partner.

Built on the ACUVUE® MOIST Platform— the #1 prescribed daily disposable brand around the globe*

Her Vision Will Change. Her Experience Won’t.

Now you can continue excellent care as her vision evolves into presbyopia NEW 1-DAY ACUVUE® MOIST Brand MULTIFOCAL Contact Lenses: Advancing multifocal lenses with pupil optimization: INTUISIGHT TM Technology The ONLY MULTIFOCAL LENS that uniquely optimizes the optical design to the pupil size for a predictable performance across the refractive range and ADD powers. PUPIL SIZE VARIES BY AGE AND REFRACTIVE POWER

Youth

Adult

Myope

Emmetrope

Hyperope

OPTICAL DESIGN For illustrative purposes only.

Continue providing the care you’ve always delivered with the multifocal lens you can rely on.

Dr. Erin Jenewein earned her Bachelor of Science degree in Biology, Chemistry and Philosophy from St. Norbert College in De Pere, Wisconsin, in 2003. She then went on to complete a Master of Science degree in Biology at the University of Wisconsin, Oshkosh, in 2005. Her thesis, Rodent Retinal Models of an Inborn Error of Sterol Metabolism, won the 2006 University of Wisconsin Oshkosh Distinguished Master’s Thesis Award. Dr. Jenewein graduated with highest honors and professional distinction from Nova Southeastern University College of Optometry in 2009 where she was awarded the Beta Sigma Kappa Silver Medal. Following graduation she went on to complete a residency at Nova Southeastern University in Pediatrics and Binocular Vision and was the recipient of the 2009 American Optometric Foundation’s Dr. Terrance Ingraham Pediatric Optometry Residency Award. In 2010, Dr. Jenewein joined the faculty at Nova Southeastern University College of Optometry and from 2010-2015 served as an Assistant Professor, Chief of Service of The Eye Care Institute at KID, and as part of the faculty of the Master of Science in Clinical Vision Research program. In 2015 Dr. Jenewein joined the faculty at Salus University Pennsylvania College of Optometry where she serves as an Assistant Professor. Dr. Jenewein has presented posters at the Association for Research in Vision and Ophthalmology, American Academy of Optometry, College of Optometrists in Vision Development and SECO International Annual Meetings, and lectured at the American Optometric Association and American Academy of Optometry’s annual meetings. Her research interests include strabismus and binocular vision disorders. Dr. Jenewein currently serves as Salus University’s Principal Site Investigator for the multi-centered NEI-funded Pediatric Eye Disease Investigator Group (PEDIG). Additionally, she is currently an investigator for the Convergence Insufficiency Treatment Trial Attention and Ready Trial (CITT-ART).

What’s up doc? Diagnosing ocular disease in kids (2 Hours – Intermediate) Category: Pediatrics As the Affordable Care Act unfolds, expanded health plan coverage may increase the number of children receiving comprehensive eye examinations, including those with undiagnosed ocular and systemic disease. This course will present a series of unusual cases to illustrate dilemmas in diagnostic testing, diagnostic technology use, and short- and long-term case management in the pediatric population. Learning Objectives: 1. Identify five systemic conditions associated with pediatric uveitis. 2. Describe diagnostic testing options in evaluating anomalous optic nerves. 3. Compare ocular manifestations of Sickle Cell Disease and Trait. 4. Specific at least four complications of Vernal Keratoconjunctivitis or its treatment. 5. Describe diagnostic testing options in diagnosing pediatric glaucoma. Learning Outcomes: At the end of this course, the course attendee should be able to identify different ocular disease conditions that are seen in children and understand the unique causes, appropriate testing methods and treatments for these conditions in the pediatric population. I.

Scleral Lenses for Regular and Irregular Corneas and Customizations for Scleral Lenses Utilizing the OCT Machine for Scleral Lens Evaluation

Stephanie Woo, OD, FAAO Lake Havasu City, AZ

Dr. Stephanie L. Woo was born and raised in Lake Havasu City, AZ. She graduated Summa Cum Laude from the University of Arizona and graduated with honors from the Southern California College of Optometry. She completed a Cornea and Contact Lens Residency at the University of Missouri, St. Louis. She is the recipient of the Gas Permeable Lens Institute Award for Clinical Excellence and also the John R. Griffin Award for Excellence in Vision Therapy. Dr. Woo is a Fellow of the American Academy of Optometry and a Fellow of the Scleral Lens Society. She authors the Gas Permeable Lens Expert column in Review of Contact Lenses, and frequently authors articles for Contact Lens Spectrum. Dr. Woo currently serves as the Public Education Chair of the Scleral Lens Society. Dr. Woo enjoys lecturing around the world on the subject of contact lenses and anterior segment disease. Dr. Woo is part owner of a three location private practice in Lake Havasu City, Arizona.

3/2/2016

Scleral Lens Applications for Regular and Irregular Corneas and Customizations of Scleral Lenses

If you feel like a patient is a good candidate for a scleral lens, please mention it!



High Myopia/Hyperopia/Astigmatism



Presbyopia



Aphakia



Anisometropia



Dry eyes with current lenses



Unhappy or unsuccessful soft toric lens patients



Current GP or piggyback wearers



Athletes

Fast forward 

Patient has been in scleral lenses for 2 years now and says, “My vision is great. I don’t have any fluctuating vision in the left eye anymore. The lenses are comfortable.”



At all follow up visits, cornea and conjunctiva have remained healthy.

Clinical Pearls Scleral lenses are EASIER to fit on normal corneas! Scleral lenses have LESS COMPLICATIONS when fit on normal corneas!  Insertion and removal important to success  Scleral lenses can be just as comfortable as soft toric lenses  The top two reasons patients drop out of contact lenses is comfort and vision – we can solve this!  

Front toric optics Lenses do not fit differently because of front toric optics • Check toric markers are on axis and stable with blink • If rotating, consider adding more prism/weight • Patient should be told how to insert for best initial vision

Front toric optics Lenses do not fit differently because of front toric optics

• Check toric markers are on axis and stable with blink • If rotating, consider adding more prism/weight • Patient should be told how to insert for best initial vision

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3/2/2016

Toric Peripheries

Final Thoughts: Front Toric Optics 

Good option for patients desiring better vision and have residual astigmatism



Can achieve better vision in office with sphero-cyl over-refraction



Not good for patients with lens flexure



Not good for patients with < 0.75 D cyl



Not good for patients with posterior cornea irregularities

The sclera close to the limbus is generally spherical Beyond 16.5mm scleral has toricity due to muscle insertions

The lens will have 3 o'clock and 9 o'clock compressions, as well as excessive lift at the 6 o'clock and 12 o'clock positions.



Many labs now offer toric back surface haptic (peripheral curves), which can dramatically improve the scleral lenses fitting relationship.

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3/2/2016

Toric Peripheries

Clues that a toric periphery is needed Fitting and dispense showed good fit without compression of edges, spherical O/R • On follow up: Patient reports vision decreases after a few hours and eyes get red on the sides after a few hours • Now O/R shows 1-1.5D of cyl • Edge tight nasal/temporal but good apposition superior/inferior

Markers on the flat meridian • Lenses will rotate into place and lock in (like a glove) • Creates great stability for front torics

Toric periphery Alternative: • Try fitting in a smaller diameter • May not be able to fit in smaller diameter if excessive vault is required

What Makes EyePrintPRO So Different? EyePrint Impression Process ◦ Takes less than 3 minutes ◦ Captures the precise curvatures of the entire ocular surface. ◦ Comfortable and gentle ◦ Safe even on transplants! Each impression is unique like a fingerprint!

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3/2/2016

There is no guessing with the EyePrintPRO!

EyePrint Prosthetics LLC

1. Impression of the ocular surface is obtained 2. Diagnostic lenses are used to determine prescription 3. Impression is sent to the lab 4. 3-D scanner design a device based on exact contours 5. The EyePrintPRO is shipped to the Havasu Eye Center for dispensing.

Impression is then analyzed by a 3-D scanner to design a device perfectly shaped to the eye

Precision = You get exactly what you need!

Regular scleral lens

EyePrintPRO

Case report

KL – 78 year old white female

Other testing 

Topography was extremely difficult, and the images were not helpful.

OD: Wet macular degeneration, corneal transplant, glaucoma surgery (bleb), and PCIOL. Her BCVA was 20/HM (15 years), and according to her retinal specialist, there was no potential for vision improvement



Side profile of her eye showed a flat corneal graft with a sunken center and a large bleb superotemporal

OS: Dry macular degeneration, corneal transplant, glaucoma surgery (bleb), and aphakic. Her BCVA was also 20/HM (20 years), and according to her retinal specialist, there was possible potential for vision improvement.



Her intraocular pressure of the left eye was 12 mmHg. The corneal graft was relatively clear and endothelial count was 1300.



Presented to the clinic for a contact lens consultation. Her current ocular status was:





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3/2/2016

Multiple lenses trialed 

Do we have ANY options?!

KL was seen multiple times and the left eye was fit with the following contact lenses:  Corneal

GP

 Reverse

Geometry GP

 Intra-limbal

designs

 Post-Transplant GP  Custom

soft lens for Transplants

 Piggyback  Scleral

designs

(high plus soft lens with GP on top)

lens



The corneal graft prevented any of the gas permeable lenses from centering, even with the high plus piggyback. Scleral lenses were not an option due to the large bleb. At this time, the EyePrintPRO was attempted.



First, an impression of the left eye’s ocular surface was obtained in office. The impression was then scanned and a 3-D image was created



Normally, diagnostic scleral lenses are used during the fitting to obtain a proper over-refraction.



However, KL’s bleb was so large that every time a scleral lens was placed on the eye, a bubble formed.



There was no useful retinoscopy or subjective refraction, so axial length and estimation of corneal shape from topography was given to the lab to estimate power.

Lens dispense

Follow up care 

Due to the possibility of unwanted pressure to the bleb, KL returned for a follow up 24 hours later. Her intraocular pressure was 11 mmHg and her cornea remained unchanged.



KL returned for a follow up 2 days later. Her intraocular pressure was 12 mmHg and her cornea remained unchanged.



KL returned for a follow up 1 week later. Her vision was 20/50 and her intraocular pressure was 11mmHg. With the device removed, her cornea showed no corneal staining or edema.



KL returned for a follow up 3 weeks later. Her vision remained at 20/50 and she was very happy with her new-found vision. Her intraocular pressure was 12 mmHg and her cornea showed no staining or edema.



Lens dispense: The EyePrintPRO lab was able to create a lens that could vault the bleb, and the lens power was estimated at -0.87 D



Upon lens insertion, the patient was immediately able to see 20/50! She had no over-refraction and the lens aligned perfectly with her ocular surface. The bleb was fully covered by the EyePrintPRO.



The patient was taught proper insertion and removal techniques along with lens care.

Other cool features of the Eyeprint

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3/2/2016

Pinguecula

Adding prism to Eyeprint 

Prism is only in optic zone



Edge quickly flattens to reduce thickness (and O2 permeability) to the rest of the cornea

• Great for glaucoma patients and suspects • Good for patients with guttata/Fuch’s

GLOBAL PACHYMETRY – PMD PATIENT

EVALUATING HYBRID LENSES

POST LASIK ECTASIA AND SCARRING

DO YOU NEED AN OCT FOR SCLERAL LENS FITTINGS? • No, but if you have an OCT machine, you can gain confidence when first learning to fit specialty contact lenses

• As an experienced scleral lens fitter, you can also compare the OCT measurements with the accuracy of your slit lamp findings

• Serves as an excellent tool for specialty contact lens fittings

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3/2/2016

SCLERAL LENS FITTING BASICS • Most scleral lenses vault the cornea and limbus completely • Ideal central clearance is between 150um-400um for most designs • Edge alignment should show an even landing zone without compression or vessel constriction

DO NOT WANT TO SEE THIS STEP ONE: INSERT SCLERAL LENS • Apply scleral lens to patient’s eye and evaluate quickly with slit lamp to check for complete central and limbal clearance

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3/2/2016

AN OPTIC SECTION EVALUATION WITH FLOURESCEIN

STEP 2: ALLOW LENS TO SETTLE 20-30 MINS • This is a critical step that cannot be skipped! • Scleral lenses are known to settle over time, and most of the settling occurs during the first 30 minutes.

• Allowing the lens to settle will give you a more accurate measurement

• Can allow novice practitioners to become more confident when first starting to fit scleral lenses

• Serves as a high standard of care for specialty contact lens fittings!

16

Notes:

Jimmy Bartlett, OD, FAAO Birmingham, AL

How to Get Comfortable with Prescription Oral Medications Are You Practicing 21st Century Therapeutics?

Jimmy Bartlett, OD, FAAO Birmingham, AL

Jimmy D. Bartlett, O.D., received his Doctor of Optometry degree from Southern College of Optometry. After serving as Chief of the Optometry Service at the Tampa V.A. Medical Center and as Assistant Professor in the Department of Ophthalmology of the University of South Florida College of Medicine, he accepted a faculty position at the School of Optometry, University of Alabama at Birmingham (UAB) in 1977. Dr. Bartlett rose through the academic ranks and served as Director of Continuing Education, Director of Residency Programs, and as Professor and Chairman of the Department of Optometry and Director of the Professional Program. He also served as Professor of Pharmacology in the Department of Pharmacology and Toxicology at the University of Alabama School of Medicine. Dr. Bartlett has served as Editor-in-Chief of Optometry—Journal of the American Optometric Association; co-editor of Clinical Ocular Pharmacology, now in its 5th edition; and he serves on the editorial advisory board for Ophthalmic Drug Facts and Journal of Ocular Pharmacology and Therapeutics. Following a 34-year career at UAB, Dr. Bartlett was appointed Professor Emeritus, and he currently serves as President of PHARMAKON Group, an advisory service to the ophthalmic pharmaceutical industry. He has published more than 240 papers and delivered more than 1,200 lectures throughout the world to both clinical and research audiences. Dr. Bartlett is the recipient of two honorary degrees, and in 2000 he was selected by Review of Optometry as one of the most influential optometrists of the 20th Century.

Know the disease state you’re treating  Know the applicable drug(s) – not all, just the few you will be using  Know your patient and ask the right questions  Don’t memorize dosages – look them up  Clinical experience is key

Select your patients carefully Treat according to your comfort level, or just a little beyond As your experience grows, so will your confidence If possible or practical, spend some time in a colleague’s office, a “referral center,” or other clinic where you can gain hands-on experience Review your cases with a trusted colleague, partner, or faculty member Remember that there are many “correct” ways to treat ocular disease

“Are you allergic to antiviral medications such as acyclovir (“Zovirax”)?” “Have you been treated before with this medicine and had to stop for any reason?” “Are you pregnant or nursing?”– get in the habit of asking this question unless the patient is not a female of childbearing potential Do you have kidney failure?

Orbital Cellulitis Marked Common Often reduced May be APD Restricted Present May be elevated Elevated (>102°)

General Treatment Strategy (Adult) Largely empirical  Penicillinase-resistant penicillin or  First-generation cephalosporin  These are cost-effective and intentionally have a narrow spectrum of activity to limit development of bacterial resistance 

As You Go From 1st to 2nd to 3rd You increase gram-negative coverage You lose gram-positive coverage  You increase cost astronomically!  So use 1st generation cephalosporins for adults and children with presumed staph infection  Use 2nd generation for children with URIs

What To Ask Before Prescribing “Are you allergic to “mycin” drugs?” “Did you have to stop treatment with a “mycin” drug for any reason?”  “Are you pregnant?”  Avoid clarithromycin in pregnancy (category C)  Azithromycin and erythromycin are cat. B  

TID QID Q 1-2 H I would prefer to use more than C, if only the patient would comply

HOW TO USE STEROIDS

Dosing Frequency and Antiinflammatory Effect of Pred Forte Dosage

In a word, “Boldly!”

Total # Drops

↓ Inflammation

1 gt q 4h

6

11%

1 gt q 2h

10

30%

1 gt q h

18

51%

1 gt q 30 min

34

61%

1 gt q 15 min

66

68%

1 gt q min x 5 min qh

90

72%

Leibowitz HM, Kupferman A. Int Ophthalmol Clin 1980; 20: 117-134.

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3/3/2016

Self-Assessment Question 1

Steroids in Microbial Keratitis

Do you always tell patients to shake steroid suspensions, and you always pulse dose? If so, give yourself 1 point  If you don’t do both of these, give yourself 0 points 

Steroids for Corneal Ulcers Trial (SCUT)

SCUT Conclusions “We found no overall difference in 3-month BSCVA and no safety concerns with adjunctive corticosteroid therapy for bacterial corneal ulcers.” “Adjunctive topical corticosteroid use does not improve 3-month vision in patients with bacterial corneal ulcers.”*

Srinivasan M, et al. Arch Ophthalmol 2012;130(2):143-150.

2016 Update 



Adjunctive topical corticosteroid therapy may be associated with improved long-term clinical outcomes in bacterial corneal ulcers not caused by Nocardia species There may be a benefit with adjunctive topical corticosteroids if application occurs earlier (after 2-3 days) in the course of bacterial corneal ulcers

*Exceptions: Patients with “finger counting” VA or worse at baseline, and patients with completely central ulcers.

2016 Update 



After controlling for visual acuity at enrollment, BSCVA was not significantly different between the corticosteroid and placebo groups at 4 years “There is inadequate evidence as to the effectiveness and safety of adjunctive topical corticosteroids compared with no topical corticosteroids in improving visual acuity, infiltrate/scar size, or adverse events among participants with bacterial keratitis.”

Doxycycline can enhance the anticoagulant effect of warfarin  This is likely due to competitive interaction for albumin binding and possibly inhibition of the cytochrome P-450 system  An increase in plasma levels of free warfarin may result in severe bleeding Hasan SA. Interaction of doxycycline and warfarin: an enhanced anticoagulant effect. Cornea 2007;26:742-3. Baciewicz AM, Bal BS. Bleeding associated with doxycycline and warfarin treatment. Arch Intern Med 2001;161:1231.

Is Your Rosacea Patient Pregnant or Allergic to Doxycycline? Or is Your Patient Taking Coumadin?

What If My Rosacea Patient Can’t Take Tetracycline? Azithromycin 500 mg 3 times/wk is at least as effective as doxycycline in the treatment of rosacea  Oral azithromycin 500 mg/day for 2 weeks is effective for treatment of intractable rosacea 

Self-Assessment Question 6 Do you advise patients on the availability of Finacea, Mirvaso, or Soolantra (by name) for the dermatologic manifestations of rosacea? If so, give yourself 1 point  If not, give yourself 0 points 

No longer considered a last resort Use when there are significant signs or more severe symptoms Limit therapy to ester-based steroids (loteprednol) In severe cases, pulse dosing is mandatory Schedule follow-up in 2-4 weeks to check IOP and therapeutic response

Allergic rhinoconjunctivitis (ARC) presents as nasal symptoms, eye watering and itching Intranasal corticosteroids (INSs) are the most effective treatment for the nasal symptoms of seasonal allergic rhinitis (SAR) and are considered first-line therapy for nasal congestion

INSs provide some relief from ocular symptoms of SAR and seasonal ARC in adults, and are better than oral antihistamines  INSs are safe for use over several months

Do you use Lotemax or Alrex as first-line therapy of patients with severe symptoms or hyperemia associated with SAC? If so, give yourself 1 point  If not, give yourself 0 points  Will you recommend INS therapy for some of your patients with ARC?  If so, give yourself a bonus point! 

Unless otherwise contraindicated, do you routinely use topical CAIs for treatment of glaucoma in patients with a history of “sulfa” allergy? If so, give yourself 1 point  If you purposefully avoid CAIs in these patients, give yourself 0 points  If you don’t treat glaucoma, give yourself 0 points 

Self-Assessment Question 10 Are you now aware of the new FDA druguse-in-pregnancy rule that became effective last June? If so, give yourself 1 point  If you were sleeping during the last 5 min, give yourself 0 points 

Intravitreal Injections: Can They Treat Everything? Oral Management of Headaches

Leonid Skorin, Jr., OD, DO, MS, FAAO, FAOCO Albert Lea, MN

Dr. Skorin is glad you’re reading his biography. He is a Consultant in the Department of Surgery, Community Division of Ophthalmology at the Mayo Clinic Health System in Albert Lea, MN and is an Assistant Professor of Ophthalmology, Mayo Clinic College of Medicine. Dr. Skorin is a Past-President of the Minnesota Osteopathic Medical Society. He is a Costin Institute Scholar in osteopathic medical education and received the Presidential Achievement Certificate for his medical and surgical mission work in Ukraine from the American Osteopathic College of Ophthalmology. In 2007 Dr. Skorin was named Distinguished Practitioner of the National Academies of Practice in the Osteopathic Medical Academy and had served as its Chair. Dr. Skorin completed the Mayo Clinic Leadership Development Program in 2010 and a Master’s of Science in Medical Education Leadership through the University of New England College of Osteopathic Medicine in 2011. He completed the American Osteopathic Association Health Policy Fellowship in 2012. He enjoys cruising the country lanes in his 1956 Chevrolet Bel-Air convertible and is an amateur herpetologist specializing in chelonians.

Dr. Thomas served as a Captain in the U.S. Air Force as a clinical optometrist at Bolling Air Force Base in Washington, D.C., from 1981 to 1984. Dr. Thomas is in a group practice in Concord, North Carolina, and serves as the Ophthalmic Drug Consultant for the Pharmacy and Therapeutics Committee of North Carolina Blue Cross and Blue Shield. He is on the hospital staff at Northeast Medical Center, where he serves as the Ophthalmic Consultant to the Diabetes Management Committee, and actively teaches on the Cabarrus Family Medicine Residency Faculty. He and Cheryl have two daughters.

Ron Melton, OD, FAAO Charlotte, NC

Dr. Melton served as a Captain in the U.S. Army as a clinical optometrist at Hawley Army Hospital in Indianapolis, Indiana, from 1981 to 1984. Currently he is in a group practice in Charlotte, North Carolina, where he has staff privileges at Presbyterian Hospital. He and Annie have two daughters and one son.

The lecture team of Ron Melton, OD, FAAO, and Randall Thomas, OD, MPH, FAAO, received the “Pioneer in Optometry” recognition by the Editorial Board of Primary Care Optometry News in April 2015 for their contributions to educating optometrists around the world in ocular disease. They are co-recipients of the 2014 Vincent Ellerbrock Clinician Educator Award by the American Academy of Optometry for outstanding and sustained contributions to the Academy’s Lectures and Workshops program. They have lectured nationally and internationally on ocular disease and pharmacology at over 1,000 continuing medical education meetings. Drs. Melton and Thomas have authored or coauthored over 100 papers on optometry and are the co-authors of the popular annual “Clinical Guide to Ophthalmic Drugs” for Review of Optometry. They have acted as investigators in more than 50 clinical research trials. Both are certified as a Diplomate, American Board of Optometry. They are full-time clinicians delivering primary and secondary eye care.

Financial Disclosure Dr. Ron Melton and Dr. Randall Thomas are consultants to, on the speakers bureau of, on the advisory committee of, or involved in research for the following companies: Allergan, ICARE, Shire and Valeant.

• 3rd nerve palsy without pupillary involvement • Can be painful or painless • Usually associated with diabetic ischemia. Recovery is usually spontaneous in 8-12 weeks

• Eye is usually down & out with marked ptosis in a complete 3rd

nerve palsy

• When pupil is involved, it is usually mid-dilated • Sudden onset of painful or painless palsy with spared pupil in the

middle-aged/elderly patient with diabetes and/or hypertension is almost always caused by microvascular disease. Recovery is expected in 8-12 weeks. • Treatment: occlude one eye or use a Fresnel prism • Sudden onset of painful palsy with pupillary involvement at any age merits an emergency workup

Then it’s nothing “bad” and a scan is not indicated Consider: Adies, pharmacologic causation, or “discovered” physiologic anisocoria as probabilities

epithelial cells that are remnants of Rathke’s pouch lying between anterior and posterior lobes of pituitary gland • Most common in children • In adults - progressive VF loss associated with endocrine disturbances and dementia • Bitemporal hemianopsia most common VF deficit (incongruous homonymous hemianopsia of optic tract origin frequent)

• Can involve: visual acuity (1/4), visual field (1/4), or both

(1/2). Bilaterally in about 65%.

• Expressed independently across socioeconomic strata • Female to male ratio: 3 to 1 • General age range: 10 to 40 years • Can occur as an overlay of organic disease in

approximately 15% of patients

• Most patients do not have psychiatric disease • About 1/3 have stress, anxiety, and depression

incidence 62) • No association with refractive error, except patients with -3.00D or more go to P.V.D. 5-10 years earlier • 80-90% of breaks associated with P.V.D. are in the superior quadrants • Within 2 years, 10% of patients will develop a P.V.D. in the fellow eye

Timing and RD Repair: Is there a hurry? • Preoperative VA is the strongest predictor of postoperative

VA

• When control vision is affected, about 30% of patients

ultimately achieve 20/40 or better

• “There is no difference in VA outcomes among patients who

underwent within the first week of onset.”

• VA can improve for months to years after surgical repair • There was no association between duration of macular

detachment and postoperative VA

• “Clinical evidence suggests that the duration of macular

detachment has a minor, if any, effect on visual outcome when repair is performed within about one week. Similarly, many fovea-sparing RD’s can likely be deferred for a short period without affecting visual outcomes.” JAMA Oph. November 2013

Optic Nerve Head Drusen • Pseudopapilledema (disc vessels can be clearly seen) • High refractile granular bodies of calcium and

amorphous granular material

• Small, translucent, yellowish pearls • Autosomal dominant (check family members) • Generally bilateral; more often nasal side of disc • Can be associated with juxtapapillary heme • May be buried in children • Rarely associated with significant loss of vision • Up to 75% have VF defects • Management: 30-2 VF, disc photos q1-2 years

Young adult with sudden visual loss Progression of symptoms of 1 wk or less Pain on eye movement Vision improvement within 1 month Afferent pupillary defect Swollen or normal disc No more than minimal vitreous cells No hx of systemic disease that might produce optic neuritis

Financial Disclosure Dr. Ron Melton and Dr. Randall Thomas are consultants to, on the speakers bureau of, on the advisory committee of, or involved in research for the following companies: Valeant, ICARE-USA, and Jobson Publishers.

Dosage is 0.5 mg P.O. once daily of fingdimod 0.7% risk of macular edema at 3-4 months Macular edema tends to be unilateral M.S. patients with D.M. and/or a history of uveitis may be slightly more at risk Mechanism of causation is unknown HD-OCT is the most reliable method to detect these changes Discontinuation reverses the macular edema Topical steroids and topical NSAID’s may hasten recovery Reference: Ophthalmology, July, 2013

Tecfidera (dimethyl fumarate) • Now FDA-approved for treatment of patients with relapsing forms of multiple sclerosis • May cause decrease in white blood cell count. Most common side effects are flushing and stomach problems, especially at start, which may decrease over time • Safety and efficacy in pediatric patients has not been established • Pregnancy category C • Manufactured by Biogen Idec Inc.

Systemic Prednisone

Non-ophthalmic steroid: ointment/cream/lotion

• Most common Rx’d systemic corticosteroid • Common initial dosage 40-60 mg • Available generically in both tablets and DosePaks (5 or 10 mg at 6 or 12 day course) • Questions to ask before prescribing?

The mainstay of therapy for contact blepharodermatitis has been a steroid ophthalmic ointment. Alternatives to loteprednol and fluorometholone ophthalmic ointment are sodium sulfacetamide/ steroid combination ointments, where the sodium sulfacetamide plays no therapeutic role. However, these combinations are a good source for prednisolone which has a moderate level of antiinflammatory activity. More recently, the use of triamcinolone cream or ointment has gained popularity in treating contact eyelid and periorbital allergic dermatitis. Instruct the patient that this treatment is not meant to go directly into the eyes, though no harm would be expected. Triamcinolone comes in different strengths and it is available generically in a 15 gram tube.

• If the regimen does not control the contact blepharodermatitis or if the reaction is severe, then systemic steroids may be necessary. In this case, a 7-10 day tapering course of oral prednisone starting with 30-40 mg would be appropriate therapy. Common precautions to oral prednisone include a history of peptic ulcer disease, poorly controlled diabetes, pregnancy or active tuberculosis • If the contact blepharodermatitis persists or becomes recurrent, then allergy testing would be indicated in an attempt to determine the possible causative agent.

• • • •

Diabetic? Peptic Ulcer Disease? Tuberculosis? Pregnant?

2

Adenoviral Infections

Adenoviral Infections

Common cause of “red eyes” Assume adenovirus until proven otherwise Often have pre-auricular node Non-purulent watery discharge Usually starts in one eye and spreads to fellow eye in a few days • Always evert lids to survey tarsal conjunctiva • With EKC, spotty sub-epithelial infiltration in 50 to 75% of untreated cases

Rule of Thumb for Calculating “Ideal” Body Weight Women: 100 lbs + 5 lbs for each >5 feet Men: 110 lbs + 5 lbs for each >5 feet Using these simple formulas can provide a quick assessment of proper dosing. Also, bear in mind that “lowering the current dose in a long-term patient does not remove cumulative risk from past exposure.” This is a critical point and one that merits the careful attention of the optometrist.

New Insights in Plaquenil Toxicity (Slide I)

10-2 VF can be more sensitive in some patients than SD-OCT • Parafoveal thinning or outer segment line break-up is associated with VF loss • Earliest VF changes in the pattern deviation probably plots may be only a couple of isolated parafoveal scotomas. We all need to be keenly aware of these VF patterns. If ever in doubt, repeat the 10-2 in a few weeks, but do not prematurely stop the drug • “Fields may be sufficient for initial screening where SD-OCT is not available, and SD-OCT change is unlikely if a reliable field shows no losses at all.” •

50% of cases were being overdosed!! Eye doctors need to take the initiative to counsel prescribing physicians of the proper daily dosage Visible fundus changes are a LATE finding of toxicity Using both a subjective test (10-2 white targets), and an objective test (SD-OCT) is now standardof-care In about 10% of cases, there can be significant defects on the 10-2 yet a normal SD-OCT!

Post-Cessation Plaquenil Retinopathy Progression •

Several patients were followed for 2 to 3 years after stopping Plaquenil therapy

•

White 10-2 fields and HD-OCT are the preferred tests to screen for, and follow hydroxychloroquine maculopathy

•

HCQ toxic effects can linger 2 to 3 years (perhaps even longer) following cessation

•

Anatomic and functional progression is very minimal if retinotoxicity is discovered before RPE observable changes (Ball’s-eye)

•

“Early recognition of HCQ toxic effects before any fundus changes are visible will greatly minimize late progression and the risk of visual loss.”

At initial screening visits about 5% of patients received a 10-2 plus one objective test (usually a HD-OCT)

•

Undertesting - - only a 10-2, or only an objective test (OCT, FAF, or mfERG) in about 30% of patients

•

No testing occurred in 25% of Plaquenil patients!

•

Amsler grid is of no value in HCQ testing, yet was done on 40% of patients. AJO, September 2015

JAMA-Oph. September 2014

Perspective on Poor Plaquenil Practice •

“Retina and comprehensive ophthalmologists see a majority of the patients for HCQ screening but are appropriately screening patients less than half the time.”

•

“The import of all the recent literature and our current study indicates that we are failing to provide patients proper HCG screening, which is of particular concern given the rising detection rate of toxicity.”

•

This study was done at a highly prestigious ophthalmology clinic in the midwest, and these results are nothing short of pitiful. Optometry can and should provide a much higher level of care! AJO, September 2015

4

Brimonidine Dermatologic Gel

Eye Whitener – Luminese • Dilute alpha-1 receptor agonist

• Used to address the erythema and flushing commonly expressed in facial and eyelid rosacea • Causes microvascular vasoconstriction • Comes in a 30 gram tube – applied once daily • Provides a “somewhat effective” clinical response • Available as a .33% gel by Gladerma

• 0.025% brimonidine is the effective dilution • Does not cause rebound hyperemia like tetrahydrozoline • Prior to commercialization of Luminese, “inoffice” dilution can be done • Use a 3 ml sample bottle of aqueous artificial tear, and using a sterile syringe, place 1 ml of 0.1% Alphagan-P into the artificial tear bottle to achieve a 0.025% solution • Use once daily, usually in the morning, to achieve protracted eye whitening.

Herpes Gladiatorum • Occurs most commonly among young wrestlers, or in other sports where there is very close skin contact. • First described in the 1960’s – NEJM • It is an expression of HSV-I • Lymph nodes (preauricular and/or submandibular) are commonly present on one or both sides • Treated with oral antiviral for a week • Like all HSV infections, can become recurrent in nature. • Temporary isolation from sports while being treated is key to breaking cycle of perpetuation

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